1. Senior clinical counsellor workshop
This workshop is aimed at staff who will be undertaking the role of Senior Clinical Counsellor within their organisations.
We will be looking at best practice for communicating with patients and carers who have been involved in a patient safety incident.
Senior clinical counsellor workshop

2. Aims To provide an overview of the Being open framework
For senior clinical counsellors to learn more about their role
For participants to learn key skills that underpin effective communication with patients, their families and carers following a patient safety incident
Notes to Facilitator:
Read the purpose of the session statements from the slide.
Many of the people who you train will already have a certain level of skill and experience in offering apologies and explanations to patients, their families and carers. It is important to recognize this at the outset of the workshop and to state that other participants who have attended the workshop and have previous experience of putting Being open into practice have found it a useful forum to reflect on their current approach to being open and further improve the skills they already have.
Some participants may have less or more limited experience of offering apologies and therefore the course materials along with the discussions within the whole group will enable skills to be developed.

3. Session 1: Background to Being open
Notes to the Facilitator
In this session we will be looking at best practice for communicating with patients and carers who have been involved in a patient safety incident.
This session replicates session 1 provided within the Gold and Silver Being open training, therefore it is important to state that the purpose of the session is to:
allow participants of all skill sets to review their skills and knowledge in Being open and to think specifically about how they can use these within their Senior Clinical Counsellor role.
To provide a foundation of understanding about the core principles and Being open process which Senior Clinical Counsellors have to champion.

4. The role of the senior clinical counsellor
Support fellow healthcare professionals with Being open
Support fellow healthcare professionals deal with patient safety incidents
Practice and promote the principles of Being open
• Support fellow healthcare professionals with Being open by:
–– mentoring colleagues during their first Being open discussion;
–– advising on the Being open process;
–– being accessible to colleagues prior to initial and subsequent Being open discussions;
–– facilitating the initial team meeting to discuss the incident when appropriate;
–– signposting the support services within the organisation for colleagues involved in
Being open discussions;
–– facilitating debriefing meetings following Being open discussions;
–– mentoring colleagues to become senior clinical counsellors.
• Support fellow healthcare professionals in dealing with patient safety incidents by:
–– signposting the support services within the organisation for colleagues involved in patient safety incident discussions;
–– advising on the reporting system for patient safety incidents.
• Practice and promote the principles ofBeing open

5. Key actions from NPSA Patient Safety Alert: (2009)
Local policy
Leadership
Responsibilities
Training and support
Visibility
Supporting patients
Note to the Facilitator:
Explain that the NPSA’s original Being open policy was launched in September The NPSA re-launched the Being open framework, along with a Patient Safety Alert in November Being Open is a set of principles that healthcare staff should use when they communicate with a patient, their family or carer(s) following a patient safety incident where the patient was harmed. The key requirements for NHS organisations from the NPSA’s Patient Safety Alert are:
Local policy: Review and strengthen local policies to ensure they are aligned with the Being open framework and embedded with your risk management and clinical governance processes
Leadership: Make a board-level public commitment to implementing the principles of Being open
Responsibilities: Nominate executive and non-executive leads responsible for leading your local policy. These can be leads with existing responsibilities for clinical governance
Training and support: Identify senior clinical counsellors who will mentor and support fellow clinicians. Develop and implement a strategy for training these staff and provide ongoing support
Visibility: Raise awareness and understanding of the Being open principles and your local policy among staff, patients and the public, making information visible to all.
Supporting patients: Ensure PALS and other staff have the information, skills and processes in place to support patients through the Being open process

6. Being open Framework guidance (2009)
Policy
Principles
Process
Patient issues
Supporting staff
Board leadership
Note to the Facilitator:
Explain that the NPSA’s original Being open policy was launched in September The NPSA re-launched the Being open framework, along with a Patient Safety Alert in November Being Open is a set of principles that healthcare staff should use when they communicate with a patient, their family or carer(s) following a patient safety incident where the patient was harmed. The key requirements for NHS organisations from the NPSA’s Patient Safety Alert are:
Local policy: Review and strengthen local policies to ensure they are aligned with the Being open framework and embedded with your risk management and clinical governance processes
Leadership: Make a board-level public commitment to implementing the principles of Being open
Responsibilities: Nominate executive and non-executive leads responsible for leading your local policy. These can be leads with existing responsibilities for clinical governance
Training and support: Identify senior clinical counsellors who will mentor and support fellow clinicians. Develop and implement a strategy for training these staff and provide ongoing support
Visibility: Raise awareness and understanding of the Being open principles and your local policy among staff, patients and the public, making information visible to all.
Supporting patients: Ensure PALS and other staff have the information, skills and processes in place to support patients through the Being open process

7. NHS Constitution (2010)
‘The NHS also commits, when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively.’
(Page 11)
Notes to Facilitator:
This slide applies to England only
The key point to state here is that Being open is part of the NHS Constitution for England, which includes the statement on the slide. This statement encourages healthcare staff to acknowledge and apologise for mistakes and to offer explanations and support when things go wrong. This is essentially what Being open is about.
When presenting a Being open workshop to a Welsh audience, it is important to use the next slide in the slide set and to hide this slide.

8. Contractual ‘duty of candour’ to drive a more open NHS culture
4 December, 2012
New rules to toughen transparency in NHS organisations and increase patient confidence have been announced following public consultation.
The government will create regulations that require the NHS England to include a contractual duty of openness in all commissioning contracts from April 2013.
NHS organisations will be required to tell patients if their safety has been compromised, apologise, and ensure that lessons are learned to prevent them from being repeated. Although all NHS organisations are currently expected to be open about mistakes, there is no contractual duty to hold them to account when this does not happen.

9. The benefits of Being open
Note to Facilitator:
The learning objectives of the benefits of Being open session are to:
Teach Senior Clinical Counsellor participants why Being open is important and the right thing for patients and carers.
Help Senior Clinical Counsellor participants to identify what is good practice following a patient safety incident.
The session uses a video clip of a mother whose child had a cochlear implant operation performed on the wrong ear to teach the learning objectives specified above. In the video clip the mother describes how the healthcare team involved in her child’s care reacted after it became apparent that the operation had been performed incorrectly.
As a facilitator you will need to:
Ensure that the mpeg files for the 2 video clips are saved in the same folder as your powerpoint presentation on your laptop.
Ensure that you have good quality speakers plugged into your laptop to ensure that the video clip is audible to the audience.
Ensure that there is flip chart paper and pens available for participants to write down their responses during the session.
Explain the format of the session (refer to the Facilitator’s Handbook) and read out the background information on the events that led to the child having the operation on the wrong ear.

10. Patient/Carer testimony
Note to Facilitator:
Read out the description of the events that led to the operation being performed on the wrong ear.
Brief the participants that you will be playing them a video of a mother who is sharing her experiences of how a healthcare team responded when it became apparent that a wrong site surgery operation had been carried out on her child.
State that the video clip relates to a real incident and is the mother’s testimony.
Brief Senior Clinical Counsellor participants that you want them to watch the video clip and will then be carrying out a group exercise linked to it afterwards..

11. Effects of patient safety incidents
On patients and carers
What would be your feelings and concerns if the patient was a member of your family?
What three things do you think patients and carers involved in this type of incident would want most?
On healthcare professionals
How would you feel if you had been one of the healthcare professionals involved?
What three things do you think healthcare teams involved in this type of incident would want most?
As the facilitator you need to explain the format of the group work session.
Split the Senior Clinical Counsellor group into smaller groups of six-eight people and allocate half of the groups as patients/carers and the other half as healthcare professionals.
State that the patients/carers and the healthcare professionals groups have 15 minutes each to discuss the two questions on the slide.
Each group should capture their responses on the flip chart paper. After fifteen minutes ask one Senior Clinical Counsellor from each group to feedback on their groups discussion. As the facilitator you should point out:
That some of the feelings and concerns felt by healthcare teams and patients/carers are similar or the same.
That the top 3 things identified relate to common themes including an apology, explanation of what went wrong, single point of communication, investigation and systems change and information on what if anything can be done to medically redress the harm.

12. Patient/Carer testimony
To round off this session a second video clip is played.
To round off this session a second video clip is played to the Senior Clinical Counsellors.
In this video clip, the mother in question describes how she would have liked the healthcare team involved in her son’s care to have reacted differently after it became apparent that the operation had been carried out on the wrong side.

13. What patients want The English public want:
34% an apology or explanation
23% an enquiry into the causes
17% support in coping with the consequences
Less important were:
11% financial compensation
6% disciplinary action
Source: MORI survey commissioned for the ‘Making Amends’ report, DOH, 2002
Notes to Facilitator:
State to the Senior Clinical Counsellors that international research on Being open /open disclosure shows that patients and carers’ usually want an apology, explanation of what went wrong, investigation and support in coping with the consequences of the incident.
In England, the findings from a survey of 400 patients who had been harmed as a result of their healthcare treatment are shown. The survey was carried out as part of the Chief Medical Officers Making Amends consultation. The findings show that when asked what was most important to them in the aftermath of an incident, patients responded that it was an apology and explanation, enquiry into the causes and support in coping with the consequences of the incident. Less important were financial compensation and disciplinary action against individual healthcare professionals.
Facilitator: make the link between the Senior Clinical Counsellor groups responses in the video-based exercise and the findings on this slide.

14. What patients want A full apology and tangible support
(Idema et al., 2008)
Information on the nature, cause and prevention of errors and emotional support
(Gallagher et al., 2003)
Notes to Facilitator:
1. Explain to the Senior Clinical Counsellors that there is also a growing body of research evidence from around the world that supports the Making Amends study’s findings about what patients want. For example, Iedema et al. (2008) found that patients want full and tangible support. Similarly a study by Gallagher (2003) which compared doctors and patients expectations about open disclosure showed that patients want information on the nature, causes and prevention of errors and emotional support, and that there was a mismatch between patients expectations and what doctors thought they should discuss.
2. At this point you may also want to refer the Senior Clinical Counsellors to research which has shown the positive impact Being open has on claims and complaints. Some examples from around the world are listed below. However, please emphasise that the NPSA and other organisations endorse Being open because it is the right and humane way to respond when things go wrong, not because it has a positive impact on claims and complaints.
There are also case studies which demonstrate how open disclosure and improving patient safety can have economic benefits. Examples include:
• The Mater Hospitals, Brisbane, Australia – the hospitals have noticed a significant reduction in claims with savings of nearly $2 million AUD over four years, and a substantial return on investment9.
• A large, academic hospital in Singapore – there has been a reduction in the number of claims after implementing their system for handling serious incidents. In the past two years, they have had no cases proceed to litigation, with estimated savings of approximately $500,000 SGD per year10.
• The University of Michigan Hospital System – the full-disclosure programme has halved the number of pending lawsuits resulting in a total average annual savings of $2 US million11.
A full list of key references can be found at the back of the Facilitator’s Guide

15. Being open and legal liability
Mater Hospitals, Brisbane, Australia. Significant reduction in claims with savings of nearly $2 million AUD over four years
Singapore: large academic hospital: no cases that proceeded to litigation for 2 years. Estimated savings of $500,000 SGD
University of Michigan: full disclosure programme halved the number of pending lawsuits. Average annual saving of $US 2 million
Explain to the Senior Clinical Counsellors that one of the barriers to Being open amongst healthcare professionals is the belief that saying sorry to patients, their families and carers is an admission of legal liability. This is not true and to implement Being open across the NHS we need to dispel this widely held myth.

16. Being open and legal liability
‘It is both natural and desirable for clinicians who have provided treatment which produces an adverse result, for whatever reason, to sympathise with the patient or patient’s relatives; to express sorrow or regret at the outcome and to apologise for shortcomings in treatment. It is most important to patients that they or their relatives receive a meaningful apology.
We encourage this and stress that apologies do not constitute an admission of legal liability. In addition, it is not our policy to dispute any payment, under any scheme, solely on the grounds of such an apology.’
NHSLA ‘Apologies and explanations (2009)
Notes to Facilitators:
The NHSLA reinforced its support for Being open with patients and their families/carers by re-issuing a circular, ‘Apologies and Explanations’ in May Explain to the Senior Clinical Counsellors that the NHSLA reinforced its support for Being open with patients and their families/carers by re-issuing a circular, ‘Apologies and Explanations’ in May 2009.
This slide applies to England only
The key message from this slide is that Being open is not usually an admission of legal liability and that NHS organisations, including the NHSLA and the Welsh Risk Pool support an open and honest approach when a patient safety incident occurs.
It is important to state that the NHSLA circular was jointly issued by the following organisations, who all support Being open: The NHSLA circular was jointly issued by the Medical Protection Society, Medical defence Union, General Medical Council, Royal College of Nursing, British Medical Association and the Medical and dental defence Union of Scotland.
If you are presenting a Being open workshop to a Welsh audience, you must replace this slide with the similar statement from the Welsh Risk Pool that appears on the following slide. The Welsh Risk Pool serve a similar function to the NHSLA for Wales.

17. Organisations supporting the Being open principles

18. Elements of the Being open framework
Notes to the Facilitator:
This part of the first session aims to give the Senior Clinical Counsellor participants some background information on the NPSA’s Being open framework.
Introduce this part of the session by explaining to Senior Clinical Counsellors that you will now give them some background information on Being open .

19. 10 Principles of Being open
Notes to the Facilitator: P 14 of guidance
Explain to the Senior Clinical Counsellors’ that the Being open policy is based on the ten key principles listed on this slide.
Read the principles from the slide. Full information on what each principle means is found in the Facilitator’s Guide. See a briefer summary of each principle below:
1 Principle of acknowledgement
All patient safety incidents should be acknowledged and reported as soon as they are identified. In cases where the patient, their family and/or their carers inform healthcare staff when something untoward has happened, it must be taken seriously from the outset. Any concerns should be treated with compassion and understanding by all healthcare staff. Denial of a patient’s concerns will make future open and honest communication more difficult.
2 Principle of truthfulness, timeliness and clarity of communication
Information about a patient safety incident must be given to patients, their families and/or their carers in a truthful, timely and open manner by an appropriately nominated person. Patients should be provided with a step-by-step explanation of what happened, that considers their individual needs and is delivered openly.   
Patients and/or their carers should receive clear, unambiguous information and be given a single point of contact for any questions or requests they may have. They should not receive conflicting information from different members of staff, and the use medical jargon, which they may not understand should be avoided.
3 Principle of apology
Patients and/or their carers should receive a meaningful apology – one that is a sincere expression of sorrow and regret for the harm that has resulted from a patient safety incident. This should be in the form of an appropriately worded and agreed manner of apology, as early as possible.
Both verbal and written apologies should be given. Verbal apologies are essential because they allow face-to-face contact between the patient, their families and/or their carers and the healthcare team. They should be given as soon as staff are aware an incident has occurred. A written apology, which clearly states that the Trust is sorry for the suffering and distress resulting from the incident, must also be given.
4 Principle of recognising patient and carer expectations
Patients and/or their carers can reasonably expect to be fully informed of the issues surrounding a patient safety incident, and its consequences, in a face-to-face meeting with representatives from the hospital. They should be treated sympathetically, with respect and consideration. Confidentiality must be maintained at all times. Patients and/or their carers should also be provided with support in a manner appropriate to their needs, such as an independent patient advocate or a translator.
5. Principle of professional support
Staff must feel supported throughout the incident investigation process because they too may have been traumatised by being involved. They must not be exposed to punitive disciplinary action, increased medico-legal risk or any threat to their professional registration.
Where there is reason to believe a member of staff has committed a punitive or criminal act, the Trust will take steps to preserve its position, and advise the member(s) of staff at an early stage to enable them to obtain separate legal advice and/or representation.
Staff may seek support from relevant professional bodies such as the General Medical Council, Royal Colleges, the Medical Protection Society, the Medical Defence Union and the Nursing and Midwifery Council.
6 Principle of risk management and systems improvement
Root cause analysis (RCA) or similar systematic incident investigation techniques should be used to uncover the underlying causes of a patient safety incident. Investigations should focus on improving systems of care, which will then be reviewed for their effectiveness. The Being open policy must be integrated into local incident reporting and risk management policies and processes.
7 Principle of multidisciplinary responsibility
Any local policy on openness applies to all staff who have key roles in patient care. Most healthcare provision involves multidisciplinary teams. This should be reflected in the way that patients, their families and carers are communicated with when things go wrong. This will ensure that the Being open process is consistent with the philosophy that incidents usually result from systems failures and rarely from the actions of an individual. To ensure multidisciplinary involvement in the Being open process, it is important to identify clinical, nursing and managerial staff who will champion it. Both senior managers and senior clinicians must participate in incident investigation and clinical risk management.
8 Principle of clinical governance
Being open requires the support of patient safety and quality improvement processes through clinical governance frameworks, in which patient safety incidents are investigated and analysed, to find out what can be done to prevent their recurrence. The findings will be disseminated to staff so that they can learn from patient safety incidents.
9 Principle of confidentiality
Policies and procedures for Being open should give full consideration of, and respect for, the privacy and confidentiality of patients, their carers and staff. Details of a patient safety incident should at all times be considered confidential. The consent of the individual concerned should be sought prior to disclosing information beyond the clinicians involved in treating the patient.
10 Principle of continuity of care
Patients are entitled to expect that they will continue to receive all usual treatment and continue to be treated with respect and compassion. If a patient expresses a preference for their healthcare needs to be taken over by another team, the appropriate arrangements should be made for them to receive treatment elsewhere.

20. Overview of Being open process
Notes to the Facilitator: P 18 of guidance
Explain to the Senior Clinical Counsellors that the Being open process involves:
Detecting that a patient safety incident has occurred and determining the level of Being open response required, which is assessed using the known or expected severity of patient harm.
Holding a preliminary team discussion (i.e. a meeting between healthcare professionals to plan the initial Being open meeting with the patient and/or carer). Emphasise that it is important to seek advice from Senior Clinical Counsellors and/or the Governance Department/Risk Management Team before the preliminary team discussion takes place because they can provide advice and guidance. Explain to the Senior Clinical Counsellors that it is at this point healthcare staff will seek their advice on Being open .
The initial Being open discussion between the selected healthcare professional(s), the patient, their family and carer(s) that should take place at the earliest opportunity. The initial Being open discussion should include a verbal and written apology, a summary of the facts known to date, an offer of practical and emotional support and decisions about what the next steps are to keep patient, their family and carer informed about the progress of the incident investigation.
Being open is not a one off event: it is a process which takes account of the needs of the patient, their family and carers. Senior Clinical Counsellors may therefore need to support healthcare staff throughout this process.
The follow-up Being open discussion with the patient, their family and carer(s) emphasises that the Being open process is not a one-off event and provides an opportunity to provide the patient, their family and carer with an update on known facts and answer questions and concerns they have raised at agreed intervals/timescales.
Completing the Being open process by ensuring that the main findings from the incident investigation are shared and information on continuity of care is provided to the patient, their family and carers.
Completing the Being open process also involves actions for healthcare teams in terms of ensuring action plans that are developed on the basis of incident investigation findings are monitored and that the key findings are shared with all relevant stakeholders to ensure lessons are learnt to prevent a recurrence of the incident as far as possible.
Documenting Being open discussions with patients, their family and carers and ensuring that incident investigation reports are stored appropriately.
Explain that it is the role of the Senior Clinical Counsellor to support other healthcare staff as appropriate throughout the Being open process.

21. Grading of patient safety incidents to determine level of response
Notes to the Facilitator: P 21 of guidance
In the NPSA’s 2009 Being open framework, the level of Being open response required is determined by the known or expected level of harm to the patient. Explain to the Senior Clinical Counsellors that in the figure shown on this slide that the levels of harm shown are NPSA classifications and that the Trust’s own terminology may be different.
A Patient safety incident: any unintended or unexpected incident that could have or did lead to harm for one or more patients receiving NHS funded healthcare. The terms ‘patient safety incident’ and ‘prevented patient safety incident’ are used to describe ‘adverse events’/‘clinical errors’ and ‘near misses’ respectively.
Explain to the Senior Clinical Cousellors’ that the NPSA’s Being open framework places no formal requirement on healthcare staff to have Being open discussions with patients, their families and carers where no harm occurred. Case by case judgement should be used to determine the benefits of Being open .
Where low harm occurred, the Being open discussion should be managed locally by the healthcare team and the principles of Being open applied during the discussion.
Where moderate, severe harm or death occurred a more formal type of Being open discussion is required which involves setting up a formal meeting with the patient, their family and/or carers. This involves applying the Being open process.

22. Key learning points - session 1
Being open is what patients, their families and carers want to happen when an incident occurs
Organisations like the NHSLA, WRP, MDU, MPS, GMC, RCN and others all support Being open
Offering an apology is not an admission of legal liability
There are ten Being open principles
The level of Being open response is determined by an initial assessment of the severity of patient harm
Read the key learning points from this slide

23. Session 2: Supporting colleagues to carry out an initial Being open discussion
Notes to the facilitator:
State that the remainder of the workshop will focus on the practical aspects of being a Senior Clinical Counsellor.
Reiterating the role of the Senior Clinical Counsellor at this point to re-focus participants attention on their role. In the NPSA’s Being open framework, the role of a senior clinical counsellor is described as follows:
 TO:
• Support fellow healthcare professionals with Being open by:
–– mentoring colleagues during their first Being open discussion;
–– advising on the Being open process;
–– being accessible to colleagues prior to initial and subsequent Being open discussions;
–– facilitating the initial team meeting to discuss the incident when appropriate;
–– signposting the support services within the organisation for colleagues involved in
Being open discussions;
–– facilitating debriefing meetings following Being open discussions;
–– mentoring colleagues to become senior clinical counsellors.
• Support fellow healthcare professionals in dealing with patient safety incidents by:
–– signposting the support services within the organisation for colleagues involved in patient safety incident discussions;
–– advising on the reporting system for patient safety incidents.
• Practice and promote the principles of Being open .

24. Being a senior clinical counsellor
Group work
How can a good senior clinical counsellor support colleagues to be open?
What are the barriers and enablers for you to do the senior clinical counsellor role in your organisation?  
Notes to the Facilitator:
The remainder of the Senior Clinical Counsellor’s training session will look at how to support colleagues to communicate with patients, families and carers. The session starts with a group work exercise which aims to get participants to think about their role by working together in small groups to brainstorm the questions on the slides.
As described previously, the Being open process involves going through the stages shown on this slide. In Session 2 participants will learn how to support colleagues to carry out an initial Being open discussion
Explain that the remainder of the session will use forum theatre based training sessions to illustrate how to support colleagues who are having a Being open discussion with a patient, their family and carers.
It is useful at this point ask the participants who has experience of learning using forum theatre as a learning tool. Provide a clear explanation of forum theatre.
For group exercise:
Introduce the session by telling participants that you want to start off by asking them to reflect on the Senior Clinical Counsellor’s role and what it entails.
Split the workshop participants into small groups of 4-6 per group and ask them to spend 10 minutes having a group discussion about the two questions on the slide (i.e. 5 minutes per question).
Ask each group to capture their responses on a piece of flip chart paper or on post it notes
Ask the group to nominate a representative who will feed back the key points of the discussion.
Capture these responses on a flip chart and reassure participants that the subsequent forum theatre sessions will help them see what being a good senior clinical counsellor looks like and how to overcome barriers to implementing their role.

25. Nick Oliver and the blood transfusion
This exercise involves actors role playing a conversation between a healthcare professional and a Senior Clinical Counsellor.
The incident involves a patient called Nick Oliver, who died after being involved in an ABO incompatible blood transfusion incident. The first forum theatre piece aims to illustrate the role of a Senior Clinical Counsellor in briefing a colleague who is preparing for an initial Being open discussion with a patient’s family/carers. The scene is a conversation between a Senior Clinical Counsellor and a consultant haematologist who is preparing an initial Being open discussion 2 days after Nick has died.
The forum theatre piece focuses on the initial Being open discussion part of a Being open conversation.
As the facilitator you will need to read out the Nick Oliver script which describes the background to this incident and forum theatre piece. You will also need to:
Explain how the forum theatre exercise works
Advise the participants to watch the actors role play the script and to identify what goes well and what needs to be improved in the Being open conversation between the consultant haematologist and the Senior Clinical Counsellor.
Advise participants that their role in the forum theatre is to act as ‘directors’ directing the actor who plays the Senior Clinical Counsellor how to support their colleague to focus their approach to the initial Being open discussion appropriately.

26. Key learning points - session 2
Advice colleagues that:
Most patients want
Acknowledgment that there has been an error
An apology (sincere, verbal and written)
An explanation
Information on what, if anything, can be done to repair the harm
Reassurance that, as far as possible, you will try to prevent recurrence
Initial aims are to:
Choose an appropriate lead ,(consider being accompanied)
Establish a relationship
Ask how people are feeling and what they need (don’t assume)
Offer and arrange a key contact
Don’t be afraid to say you don’t know yet
Read the key learning points for the session from the slide. These learning points consolidate what participants have been taught throughout the session.

27. Session 3: Supporting colleagues to discuss incident investigation findings and to complete the Being open process
Introduce Session 3 by explaining that you will be focusing on how to support colleagues to discuss incident investigation findings with patients, their families and/or carers and to complete the Being open process. Like the preceding session you will be using forum theatre to illustrate key points

28. Janine Taylor and the spinal board
This exercise involves actors role playing a conversation between a senior clinical counsellor and an A&E consultant about a patient called Janine Taylor.
In the scenario, you will see the actors role play a senior clinical counsellor who is explaining how to discuss the incident investigation findings with an A&E consultant who is planning the next Being open discussion with a family of a patient who has mental ill health.
As the facilitator you will need to read out the script which describes the background to this incident and forum theatre piece. You will also need to:
Briefly re-iterate how the forum theatre exercise works
Advise the participants to watch the actors role play the script and to identify what goes well and what needs to be improved in the Being open conversation between the senior clinical counsellor and the A&E consultant
Advise participants that their role in the forum theatre is to act as ‘directors’ directing the actor who plays the healthcare professional how to improve the non-verbal and verbal elements of the conversation.

29. Key Being open issues Discussion
What’s the time frame for completing an incident investigation and how would you keep patients, their families or carers updated?
What other patient groups may have different needs during the Being open process? How would you manage them?
How would you deal with a colleague who was reticent about Being open ?
Note to facilitators:
This slide aims to consolidate the learning for 3 key issues in the Janine Taylor and the spinal board scenario. As a facilitator, you should hold a group discussion, covering one question at a time. Remember that you have 15 minutes to complete this part of the session; question 3 is likely to require a more in-depth discussion than the first two questions, so allocate time appropriately to ensure that there is a good discussion of question 3.
1.What’s the time frame for completing an incident investigation and how would you keep patients, their families or carers updated?
By asking these questions you can remind participants of the importance of the Senior Clinical Counsellor’s role in ensuring ‘follow up discussions’ occur after the initial Being open discussion and before the incident investigation findings are known.
2. What other patient groups may have different needs during the Being open process? How would you manage them?
By asking these questions you will reinforce the learning point that Senior Clinical Counsellors should refer to the Being open framework (NPSA, 2009) and ensure that they understand what this document advises about patient groups who have different needs.
3. How would you deal with a colleague who was reticent about Being open ?
This question will prompt a group discussion about how to manage colleagues who do not want to engage in Being open . By posing the question to the group as a whole you will reinforce learning and should aim to identify advice that Senior Clinical Counsellors can use if they find themselves in this situation.
When facilitating this question, facilitators should be aware of the following issues:
Firstly, most healthcare staff may be reticent because they are worried about how patients, their families and/or carers will react to the truth. Often, healthcare professionals assume that they will be angry and that their immediate response will be to sue the healthcare organisation. So it is important to find out the underlying reasons for a colleagues reticence and provide reassurance, referring back to the research evidence that has been presented in session 1. That is to say, that research shows that Being open helps patients deal with the psychological trauma of being involved in an incident. Also, most patients want an apology, explanation, practical and emotional support, and reassurance that as far as possible, the organisation will do everything to prevent a recurrence.
Hence, the first key point here is to understand the reasons for a colleagues reticence to be open and not assume that he/she is ‘a difficult person.’
It is also important to provide reassurance to colleagues that national agencies and professional bodies support Being open , as concerns about legal liability also act as a barrier. If it becomes apparent to a Senior Clinical Counsellor that this is the underlying reason for reticence, the SCC should provide reassurance that Being open is not an admission of legal liability.
Finally, sharing positive experiences through storytelling is another good strategy for Senior Clinical Counsellors to use to encourage reticent colleagues. That is to say, share experiences of where a Being open discussion has been held that led to a positive outcome.

30. Process completion Discuss findings of investigation and analysis
Inform on continuity of care
Share summary with relevant people
Monitor how action plan is implemented
Communicate learning with staff
Facilitators notes:
The Being open process is completed when the actions on the slide have been carried out. Note that some of the bullet points mentioned on this slide will have been discussed in the Janine Taylor scenario because workshop participants tend to bring them up as this scenario is delivered. Where this has occurred, refer back to the Janine Taylor scenario to make links between what the trainees have directed the actors to do and the key points listed on this slide.
Points to note when presenting this slide are:
Discuss findings of investigation and analysis (state that this is what you have focused on in Session 3)
Inform on continuity of care (i.e. if the healthcare team has not already done so, they should discuss continuity of care with the patient). State that this has been covered in the Janine Taylor scenario.
Share summary with relevant people (for example, other healthcare providers treating the patient or the coroner when a patient has died).
 Monitor how action plan is implemented (i.e. where an incident has occurred the Trust will develop an action plan and it is important that this is monitored over time.
Communicate learning with staff (i.e. it is important that the learning from the incident investigation and Being open process is shared with other members of the healthcare team).

31. Key learning points – session 3
As a senior clinical counsellor:
Ask colleagues to simulate their planned conversation (watch out for blame, speculation and the wording/tone of the apology)
Ask what support the healthcare team need
Ensure colleagues understand Being open and the incident investigation process
Advise colleagues to stick to the facts as they are known
Signpost staff to risk management and PALS
Ensure the Next of Kin has been established
Ensure the needs of different patients are considered
Make sure colleagues understand the importance of providing regular updates
Note to the Facilitator:
This slide summarises the key learning points from this session.
Read the key points from the slides back to workshop participants at the end of the session to reinforce what they have learnt.

32. Any questions?
Further information can be found at:
Notes to Facilitator:
As you close the session and signpost workshop participants to further information, state that the workshop workbook has a summary of the Being open process on the back page.